Case: U.S. v. State of New Mexico

1:07-cv-00470 | U.S. District Court for the District of New Mexico

Filed Date: May 14, 2007

Closed Date: Oct. 17, 2011

Clearinghouse coding complete

Case Summary

Pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, the Civil Rights Division of the U.S. Department of Justice ("DOJ") conducted an investigation of conditions at the Ft. Bayard Medical Center ("Ft. Bayard"), a public nursing home facility in southwest New Mexico, operated by the state in an old military facility. The investigation resulted in a May 1, 2006, findings letter being sent by DOJ to the governor. The letter stated that in July and October 20…

Pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, the Civil Rights Division of the U.S. Department of Justice ("DOJ") conducted an investigation of conditions at the Ft. Bayard Medical Center ("Ft. Bayard"), a public nursing home facility in southwest New Mexico, operated by the state in an old military facility. The investigation resulted in a May 1, 2006, findings letter being sent by DOJ to the governor. The letter stated that in July and October 2005, the DOJ conducted an investigation of the facility pursuant to CRIPA authority. The investigation relied upon site visits by DOJ personnel and consulting experts, reviews of medical records and facility documents setting out procedures, policies, and practices, and interviews of Ft. Bayard administrators, professionals, staff, and residents.

The letter noted that earlier, when concluding the first of the on-site visits, the DOJ expressed to state personnel "deep concerns" concerns about the life-threatening conditions at the facility. These prompted the Chief of the DOJ Civil Rights Division's Special Litigation Section to send a July 25, 2005 letter to counsel for the State of New Mexico. That letter memorialized the concerns and documented the nursing home's inadequate medical care and dangerous psychotropic medication usage, requesting that the State take immediate remedial action to address the most serious deficiencies. By the time of the second on-site visit, according to the May 2006, findings letter, the State had taken several steps to begin to remedy the deficiencies that had been identified.

Significant deficiencies remained, however, such that the findings letter advised the state that residents of Ft. Bayard suffered significant harm and risk of harm from (1) the facility's inadequate medical and nursing care services; (2) improper and dangerous psychotropic medication practices; (3) failure to provide adequate safety; (4) inadequate nutritional and hydration services; and (5) inadequate restorative care and specialized rehabilitation services. Additionally, the investigation found that the state failed to provide services to certain Ft. Bayard residents in the most integrated setting, as required by the Americans with Disabilities Act ("ADA"), 42 U.S.C. § 12132 et seq.

In every medical record reviewed, the DOJ consultants found substantial departures from the generally accepted standards in nursing home care. In nearly every record reviewed where psychotropic medication was prescribed, there were often multiple failings, including: the absence of a diagnosis justifying the use of the medication; the absence of behavioral indications warranting the administration of the medication; the absence of any evidence that non-medication interventions were tried and/or considered and found ineffective; the absence of monitoring of the medication's efficacy; the absence of side-effect monitoring; the absence of appropriate response to medication side-effects; and the absence of informed consent for the use of the medication. Relatedly, DOJ found that medications were also prescribed in excessive dosages.

The letter set out specific examples of deaths, pain, and suffering resulting from the many deficient practices at Ft. Bayard. Additionally, the investigation noted a possibility that Ft. Bayard staff may have allowed residents to suffer needless pain while staff members took (or sold) pain medication intended for residents. Residents were often at risk from falls, yet few had sufficient fall prevention planning provided for them. Others would repeatedly become combative with other residents or staff without adequate interventions from staff to ameliorate the harm or risk of harm. The environment itself at Ft. Bayard was unsuited for usage as a nursing home, according to the findings letter. The DOJ also found that Ft. Bayard's nutritional and hydration services substantially departed from generally accepted professional standards of care and that the nursing home offered grossly substandard activity programs for its residents. While most residents were appropriately placed in a nursing home and their reintegration in the community would be inappropriate, those able to and who could benefit from community residence were deprived of that option by Ft. Bayard's inadequacies in assessing and planning for such transitions, as well as by the state's few non-nursing home resources for such persons.

The DOJ findings letter proposed what it termed as "minimal" remedial actions to remedy the deficiencies, invited the state to address the issues, and alerted the state to the possibility of a CRIPA lawsuit brought by the United States to compel remedial action.

The DOJ's letter described a cooperative approach with the state during the course of the investigation. This atmosphere evidently continued during ensuing negotiations, because the state and the DOJ soon entered into a settlement agreement obligating the state to improve a wide range of policies and practices at Ft. Bayard. The settlement contained substantive provisions addressing (1) timely assessments and care planning, (2) safe and appropriate psychotropic medication usage, (3) improved and appropriate pain management practices, and disciplinary reporting of employee diversion of residents' medications, (4) adequate protection of residents from harm from neglect, abuse, and assaults, (5) fall prevention, (6) appropriate nutrition and hydration services, and aspiration prevention, (7) activities program improvements, (8) improvements in environmental aspects of the facility, particularly increasing privacy, (9) treatment in the most integrated setting appropriate to individualized needs, and (10) compliance with applicable federal laws and implementing regulations, including Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395i-3 et seq.; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396r et seq.; Title II of the Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12132 et seq.; and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794.

The settlement allowed for DOJ and its consultants to retain access to Ft Bayard, its residents, and documents and records, for monitoring and technical assistance purposes. The state had to implement the changes called for in the settlement document which, by its terms, expired in two years.

Attorneys for the state and DOJ signed and filed the agreement on or about May 14-16, 2007, in the U.S. District Court for the District of New Mexico and, at the same time, the United States filed its complaint against the state and the state official responsible for the operation of Ft. Bayard. The CRIPA-based complaint sought declaratory and injunctive relief, citing the deficiencies at the facility and alleging that the defendants' conduct violated residents' federal constitutional, statutory, and regulatory rights, including those due process protections provided by the Fourteenth Amendment, and the statutory protections provided by Social Security Act, the ADA, and the Rehabilitation Act (and implementing regulations).

On Jan. 28, 2008, the parties jointly moved to partially dismiss the settlement agreement. In the motion, the DOJ stated that after a number of visits, it was satisfied that the facility was in compliance with the Environment and Most Integrated Setting sections of the settlement agreement. The other aspects of the settlement agreement were not affected by the motion. The Court (Judge William P. Johnson) granted the motion on Feb. 5.

On Oct. 8, 2008, Judge Johnson granted a joint motion to extend the effective date of the settlement agreement until Nov. 2011. The Court also required that the defendants submit to the DOJ plans of correction setting forth the tasks and timetables for the state to come into compliance with all the settlement agreement provisions.

On Oct. 11, 2009, Judge Johnson accepted the parties joint corrective action plan outlining timetables for implementing the settlement agreement.

On Oct. 17, 2011, Judge Johnson granted the parties' joint motion to dismiss the complaint. The parties agreed that the facility was in substantial compliance with the settlement agreement.

Summary Authors

Mike Fagan (6/23/2008)

Andrew Junker (11/3/2014)

People


Judge(s)

Johnson, William Paul (New Mexico)

Svet, Don J. (New Mexico)

Attorneys(s) for Plaintiff

Brown Cutlar, Shanetta Y. (District of Columbia)

Deerinwater, Verlin Hughes (District of Columbia)

Delaney, Joshua (District of Columbia)

Gomez, Larry (New Mexico)

Gonzales, Alberto (District of Columbia)

Iglesias, David C. (New Mexico)

Kim, Wan J. (District of Columbia)

Mitchell, Jan Elizabeth (New Mexico)

Judge(s)

Johnson, William Paul (New Mexico)

Svet, Don J. (New Mexico)

Attorneys(s) for Plaintiff

Brown Cutlar, Shanetta Y. (District of Columbia)

Deerinwater, Verlin Hughes (District of Columbia)

Delaney, Joshua (District of Columbia)

Gomez, Larry (New Mexico)

Gonzales, Alberto (District of Columbia)

Iglesias, David C. (New Mexico)

Kim, Wan J. (District of Columbia)

Mitchell, Jan Elizabeth (New Mexico)

Preston, Judith (Judy) C. (District of Columbia)

Attorneys(s) for Defendant

Kunkel, Kathyleen M. (New Mexico)

Madrid, Patricia A. (New Mexico)

Documents in the Clearinghouse

Document

Docket (PACER)

U.S. v. State of New Mexico

Oct. 17, 2011 Docket

CRIPA Investigation of Fort Bayard Medical Center, Bayard, New Mexico

DOJ CRIPA Investigation of Fort Bayard Medical Center, Bayard, New Mexico

No Court

May 1, 2006 Findings Letter/Report
1

Complaint

May 14, 2007 Complaint
2

Settlement Agreement

May 17, 2007 Settlement Agreement
4

Order Entering Joint Motion and Stipulation for Partial Dismissal of Settlement Agreement

USA v. State of New Mexico

Feb. 5, 2008 Order/Opinion
10

Joint Motion to Accept Corrective Action Plan As Order of the Court

USA v. State of Mexico

Aug. 4, 2009 Settlement Agreement
13

Order Dismissing Complaint and Court Orders

USA v. State of New Mexico

Oct. 17, 2011 Order/Opinion

Docket

Last updated May 12, 2022

ECF Number Description Date Link
1

COMPLAINT against State of New Mexico Department of Health (Filing fee $ 350.), filed by United States of America. (Attachments: # 1 Exhibit Certificate of Attorney General)(Mitchell, Jan) (Entered: 05/14/2007)

May 14, 2007

Judge William P. Johnson and Don J. Svet assigned. (nm) (Entered: 05/14/2007)

May 14, 2007
3

Joint MOTION to Dismiss and Stipulation for Partial Dismissal of Settlement Agreement by United States of America. (Mitchell, Jan) (Entered: 01/28/2008)

Jan. 28, 2008
4

ORDER by Judge William P. Johnson granting 3 Joint Motion and Stipulation for Partial Dismissal of the Settlement Agreement AS FURTHER DESCRIBED HEREIN. (mag) (Entered: 02/05/2008)

Feb. 5, 2008
5

NOTICE by United States of America of Withdrawal of Appearance of Joshua Delaney (Mitchell, Jan) (Entered: 03/05/2008)

March 5, 2008
6

Joint MOTION to Extend (other) Dates of Settlement Agreement by United States of America. (Mitchell, Jan) (Entered: 08/25/2008)

Aug. 25, 2008
7

ORDER by District Judge William P. Johnson granting 6 ORDER on Motion to Extend dates of settlement agreement (vv) (Entered: 10/08/2008)

Oct. 8, 2008
8

Joint MOTION to Extend (other) Dates of Settlement Agreement and to Require Plans of Correction by United States of America. (Mitchell, Jan) (Entered: 04/02/2009)

April 2, 2009
9

ORDER by District Judge William P. Johnson granting 8 Motion to Extend dates of settlement agreement (vv) (Entered: 05/28/2009)

May 28, 2009
10

Joint MOTION for Order to Accept Corrective Action Plan by United States of America. (Attachments: # 1 Exhibit Corrective Action Plan (CAP), # 2 Exhibit CAP Exh 1, # 3 Exhibit CAP Exh 2, # 4 Exhibit CAP Exh 3, # 5 Exhibit CAP Exh 4a, # 6 Exhibit CAP Exh 4b, # 7 Exhibit CAP Exh 5, # 8 Exhibit CAP Exh 6, # 9 Exhibit CAP Exh 7, # 10 Exhibit CAP Exh 8, # 11 Exhibit CAP Exh 9, # 12 Exhibit CAP Exh 10, # 13 Exhibit CAP Exh 11, # 14 Exhibit CAP Exh 12, # 15 Exhibit CAP Exh 13, # 16 Exhibit CAP Exh 14 Pt 1, # 17 Exhibit CAP Exh 14 Pt 2, # 18 Exhibit CAP Exh 15, # 19 Exhibit CAP Exh 16, # 20 Exhibit CAP Exh 17, # 21 Exhibit CAP Exh 18, # 22 Exhibit CAP Exh 19, # 23 Exhibit CAP Exh 20, # 24 Exhibit CAP Exh 21, # 25 Exhibit CAP Exh 22, # 26 Exhibit CAP Exh 23, # 27 Exhibit CAP Exh 24, # 28 Exhibit CAP Exh 25, # 29 Exhibit CAP Exh 26, # 30 Exhibit CAP Exh 27, # 31 Exhibit CAP Exh 28, # 32 Exhibit CAP Exh 29, # 33 Exhibit CAP Exh 30, # 34 Exhibit CAP Exh 31)(Mitchell, Jan) (Entered: 08/04/2009)

Aug. 4, 2009
11

ORDER entering Corrective Action Plan as an order of the court by District Judge William P. Johnson granting 10 Motion for Order (vv) (Entered: 08/12/2009)

Aug. 11, 2009
12

Joint MOTION to Dismiss Complaint and Court Orders by United States of America. (Mitchell, Jan) (Entered: 10/13/2011)

Oct. 13, 2011
13

ORDER dismissing complaint and court orders by District Judge William P. Johnson granting 12 Motion to Dismiss (vv) (Entered: 10/17/2011)

Oct. 17, 2011

State / Territory: New Mexico

Case Type(s):

Nursing Home Conditions

Special Collection(s):

Olmstead Cases

Key Dates

Filing Date: May 14, 2007

Closing Date: Oct. 17, 2011

Case Ongoing: No

Plaintiffs

Plaintiff Description:

U.S. Department of Justice (on behalf of residents of the Fort Bayard Medical Center)

Plaintiff Type(s):

U.S. Dept of Justice plaintiff

Attorney Organizations:

U.S. Dept. of Justice Civil Rights Division

Public Interest Lawyer: Yes

Filed Pro Se: No

Class Action Sought: No

Class Action Outcome: Not sought

Defendants

State of New Mexico, State

Department of Health, State

Fort Bayard Medical Center (Baynard), State

Defendant Type(s):

Hospital/Health Department

Case Details

Causes of Action:

Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997 et seq.

Americans with Disabilities Act (ADA), 42 U.S.C. §§ 12111 et seq.

Section 504 (Rehabilitation Act), 29 U.S.C. § 701

Availably Documents:

Trial Court Docket

Complaint (any)

Injunctive (or Injunctive-like) Relief

Outcome

Prevailing Party: Plaintiff

Nature of Relief:

Injunction / Injunctive-like Settlement

Source of Relief:

Settlement

Form of Settlement:

Court Approved Settlement or Consent Decree

Order Duration: 2007 - 2011

Content of Injunction:

Reasonable Accommodation

Monitor/Master

Monitoring

Issues

General:

Aggressive behavior

Confinement/isolation

Deinstitutionalization/decarceration

Food service / nutrition / hydration

Habilitation (training/treatment)

Housing

Individualized planning

Neglect by staff

Rehabilitation

Discrimination-basis:

Disability (inc. reasonable accommodations)

Disability:

disability, unspecified

Integrated setting

Least restrictive environment

Mental impairment

Mental Disability:

Intellectual/developmental disability, unspecified

Mental Illness, Unspecified

Medical/Mental Health:

Medical care, general

Medication, administration of

Untreated pain

Type of Facility:

Government-run

Benefit Source:

Medicaid